Right-to-Know Request Form

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Date Requested

Date Requested

Request Submitted by:

E-Mail

U.S. Mail

Fax

In-Person

Request Submitted to:

(Agency Name and Address)

Name of Requester:

Address

City

State

Zip Code

Telephone

(Optional)

Email

(Optional)

Records Requested:

Provide as much specific detail as possible so the agency can identify the information. Please use additional sheets if necessary

Do You Want Copies?

Yes

No

Do You Want to Inspect the Records?

Yes

No

Do You Want Certified Copies of Records?

Yes

No

Do You Want to Be Notified in Advance if the Cost Exceeds $100?

Yes

No

** Please Note: Retain a Copy of This Request for Your Files **

** it is a Required Document if You Would Need to File an Appeal **

Open-Records Officer:

I have provided notice to appropriate third parties and given them an opportunity to object to this request

Date Received by the Agency:

Date Received by the Agency:

Agency Five (5) Business Day Response Due:

Agency Five (5) Business Day Response Due:

**Public bodies may fill anonymous verbal or written requests. If the requestor wishes to pursue the relief and remedies provided for in this Act, the request must be in writing. (Section 702.) Written requests need not include an explanation why information is sought or the intended use of the information unless otherwise required by law. (Section 703.)